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Please print or type. Farm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000152025 2 800-483-3718 006776967SKS 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) JC Trucking Inc 1415 W.Anderson St. Stockton CA,95206 Generators Phone: 209-466-3282 6.Transporter 1 Company Name U.S.EPA ID Number Safety-Kleen Systems,Inc. TXR000081205 7.Transporter 2 Company Name U.S.EPA ID Number Clean Harbors Environmental Services,Inc. MAD039322250 8.Designated Facility Name and Site Address U.S.EPA ID Number Clean Harbors Environmental Services,Inc. NED981723513 2247 South Highway 71 Kimball NE,69145 Facility's Phone: 308-2354012 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1.UN1263,WASTE UN1263,WASTE PAINT,3,PG 11,3,PG II D001 1D005 '0006 0, , I f � X 2 CF 1000 P � D007 1212 1 Z 2. LU 3. — _1 1 4. 14.Special Handling Instructions and Additional Information Line 1:Profile:1723603; 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified.packaged, marked and labeled/placarded.and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators/Offerors Pdntedrryped Name Signature Month Day Year SIGNATURE ON FILE SIGNATURE ON FILE 02 14 2019 .i 16.International Shipments i— 11 Impart to U.S ❑Export from U.S. Part of entry/exit: z Transporter signature for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year a SIGNATURE ON FILEI SIGNATURE ON FILE I 02 I 14 12019 N Z Transporter 2 Printed/Typed Name Signature Month Day Year Bruce Bartlett Bruce Bartlett 02 19 2019 H 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181h.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: w 18c.Signature ofAlternate Facility(or Generator) Month Day Year Q z v519.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. H040 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year JODY FIEHTNER JODY FIEHTNER 02 28 2019 EPA Form 8700-22(Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM